Perioperative care
All children need to have a
history and examination:
•
The presenting complaint should be
documented and confirmed.
•
Previous
medical history, medication, and allergies must be recorded.
•
A
brief clinical examination should be performed. In the case of undescended
testes, hydroceles, and inguinal hernias a mark should be made on the child’s
thigh to document the side for operation (away from the surgical field to
prevent tattooing of the wound).
•
If the
child is unwell with an intercurrent illness, discuss with the anaesthetist who
may decide that the child is unfit for anaesthesia.
These should be kept to a minimum.
Children undergoing major surgery should have the following done:
•
Haemoglobin
checked and blood cross-matched, according to the nature of the operation
(usually one unit of blood is sufficient).
•
Urea
and electrolytes should be checked pre-operatively in children taking
diuretics, children in renal failure, and children receiving IV fluids.
•
Children
at risk of sickle cell disease or thalassaemia should be screened in
outpatients before admission.
This is essential for safe
induction of anaesthesia. Recommendations from the Association of Paediatric
Anaesthetists.
The anaesthetist will visit
pre-operatively and discuss anaesthesia and post-operative analgesia with the
child and parents. In some instances pre-medication may be appropriate.
•
IV
access will be obtained during induction of anaesthesia and it is sensible to
pre-empt this by applying local anaesthetic ointment (e.g. EMLAâ„¢) under
occlusive dressings to the back of the child’s hands or feet, provided a
suitable vein is visible.
•
Some
anaesthetists are happy for children to come down to theatre wearing their
pyjamas; others may request a theatre gown.
•
Paediatric
anaesthetists generally encourage one parent to accompany the child to the anaesthetic room and many will be happy
for the parent to remain with the child during induction.
Pre-operative resuscitation and
preparation are essential if the outcome of surgery is to be successful.
Newborns with congenital malformations will be admitted to a neonatal intensive
care unit.
This should include:
•
Intramuscular
vitamin K.
•
FBC to
determine the haemoglobin.
•
Cross-matching
blood. Many laboratories require a sample of maternal blood for typing and this
should accompany the baby if the mother is unable or unfit to travel.
Babies with OA and anorectal
malformations should undergo echocar-diography before surgery because of the
possible cardiac defects in the VATER association.
Provided the baby passes urine
(indicative of functioning nephrons) renal imaging can be arranged electively.
Anuria necessitates a renal US scan to exclude renal agenesis.
Babies will require:
•
IV fluid: normal maintenance is required.
Babies with gastroschisis lose fluid
and heat rapidly from the exposed bowel. The baby’s abdomen should be wrapped
circumferentially in Clingfilmâ„¢ (this does not need to be sterile). Regular
bolus infusions of 4.5% albumin solution should be given before closure of the
defect.
•
NG decompression: a wide bore NGT is necessary to
empty the stomach (8 or 10 French
gauge). The NGT should be aspirated every hour and left on free drainage. NG
aspirates should be replaced mL for mL with 0.9% saline with 20mmol KCI/L, in
addition to maintenance fluids.
Biochemistry
and acid–base balance: necessary
in babies with prolonged vomiting (e.g.
pyloric stenosis).
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